Advance directives should be made and signed while a person is in good health and in a state of mind to make decisions about what should happen if he or she becomes incapacitated (e.g., during a critical illness). Families help to make decisions based on written advance directives, but families are not responsible for developing them for the patient. Developing advance directives during the admission process is not feasible, and the patient may not be capable of making an advance directive. The surrogate or proxy is one who has been already designated by a person to make healthcare decisions based on written advance directives.

2. A critically ill patient has a living will in his chart. His condition has deteriorated. His wife says she wants everything done, regardless of the patients wishes. Which ethical principle is the wife violating?

a.

Autonomy

b.

Beneficence

c.

Justice

d.

Nonmaleficence

ANS: A

Autonomy is respect for the individual and the ability of individuals to make decisions with regard to their own health and future. The wife is violating the patients autonomy in decision making. Beneficence consists of actions intended to benefit the patients or others. Justice is being fair. Nonmaleficence is the duty to prevent harm.

A signed donor card ensures that organ donation will occur in the event of brain death.

c.

A surrogate is a competent adult designated by a person to make healthcare decisions in the event the person is incapacitated.

d.

A persistent vegetative state is the same as brain death in most states.

ANS: C

A surrogate is a competent adult designated by a person to make healthcare decisions if that person becomes incapacitated. A living will is a witnessed document that states a persons wishes regarding life-prolonging procedures, whereas a healthcare proxy is a person authorized by state statute to make healthcare decisions. In many states, consent by family members or healthcare proxy is required for organ donation even if an individual has a signed donor card. A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact; brain death is cessation of brain function.

It is not necessary for a physician to write do not resuscitate orders in the chart if a patient has a healthcare surrogate.

c.

Slow codes are ethical and should be considered in futile situations if advanced directives are not available.

d.

Withholding extraordinary resuscitation is legal and ethical if specified in advance directives and physician orders.

ANS: D

Withholding resuscitation and other care is legal and ethical if based on the patients wishes. Formal orders should be written that specify what is to be done if a patient suffers a cardiopulmonary arrest. Family presence during resuscitation and invasive procedures should be encouraged. A written order for do not resuscitate must be documented in the medical record. The decision to write the order is made in collaboration with the healthcare surrogate. Slow codes sometimes occur in the clinical setting while attempts are made to contact the healthcare surrogate or proxy; however, they are neither legal nor ethical. Specific written orders determine what is to be done for resuscitation efforts.

DIF: Cognitive Level: Analysis REF: p. 33

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

5. The nurse is caring for an elderly patient who is in cardiogenic shock. The patient has failed to respond to medical treatment. The intensivist in charge of the patient conducts a conference to explain that they have exhausted treatment options and suggest that the patient be made a do not resuscitate status. This scenario illustrates the concept of:

a.

brain death.

b.

futility.

c.

incompetence.

d.

life-prolonging procedures.

ANS: B

This is the definition of futility. Brain death is cessation of brain function and is not described in this scenario. Incompetence (in this chapter) is when a patient is unable to make decisions regarding healthcare treatment. A life-prolonging procedure is one that sustains, restores, or supplants a spontaneous vital function.

DIF: Cognitive Level: Analysis REF: p. 28, 33

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

6. The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The patients Glasgow Coma Score is 3 and intermittently withdraws when painful stimuli are introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The physician explains to the family that the patient has severe neurological impairment and he does not expect the patient to recover consciousness. The nurse recognizes that this patient is:

a.

an organ donor.

b.

brain dead.

c.

in a persistent vegetative state.

d.

terminally ill.

ANS: C

A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact purposefully with the environment. She is not brain dead, as occasionally she reacts to painful stimuli and takes a spontaneous breath; therefore, she cannot be an organ donor at this time. Treatment of her condition may be considered futile; however, she would not be defined as terminally ill.

DIF: Cognitive Level: Analysis REF: p. 34 | Table 3-2

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

7. A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit a patients response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of:

a.

beneficence.

b.

fidelity.

c.

nonmaleficence.

d.

veracity.

ANS: C

Nonmaleficence is not to intentionally harm others. Beneficence demonstrates actions intended to benefit the patients or others. Fidelity is the moral duty to be faithful to the commitments that one makes to others. Veracity is the obligation to tell the truth.

9. The nurse is caring for a patient who is not responding to medical treatment. The intensivist holds a conference with the family, and a decision is made to withdraw life support. The nurses religious beliefs are not in agreement with withdrawal. However, she assists with the process to avoid confronting the charge nurse. Afterward she feels guilty and believes she killed the patient. This scenario is likely to cause:

a.

abandonment.

b.

family stress.

c.

moral distress.

d.

negligence.

ANS: C

Moral distress occurs when the nurse acts in a manner contrary to personal or professional values. Abandonment is defined as the unilateral severance of a professional relationship while a patient is still in need of health care. Family stress would not be impacted in this situation if the nurse responded appropriately during the procedure. Negligence is failure to act according to the standard of care.

DIF: Cognitive Level: Comprehension REF: p. 29

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

10. The nurse is caring for a patient who has been declared brain dead. The patient is considered a potential organ donor. In order to proceed with donation, the nurse understands that:

a.

a signed donor card mandates that organs be retrieved in the event of brain death.

b.

after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room.

c.

the healthcare proxy does not need to give consent for the retrieval of organs.

d.

once a patient has been established as brain dead, life support is withdrawn and organs are retrieved.

ANS: B

After brain death has been determined, the organs must be perfused to maintain viability. Therefore, the patient remains on life support even though he or she is legally dead. A signed donor card indicates the individuals wishes; however, most organ procurement agencies require family consent even if a donor card has been signed. In most states, the healthcare surrogate or proxy is required to give consent for organ donation. After brain death has been determined, perfusion and oxygenation of organs are maintained until organs can be removed in the operating room.

DIF: Cognitive Level: Analysis REF: p. 34

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

11. The nurse is caring for a patient who is declared brain dead and is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and writes in the progress note that the patient is brain dead. 1400 Patient is taken to the operating room for organ retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows flatline. What is the official time of death recorded in the medical record?

a.

1300

b.

1330

c.

1400

d.

1800

e.

1810

ANS: B

The time of death is when brain death is confirmed and documented in the chart, even though the patients heart is still beating. Organs are retrieved after brain death has been documented.

DIF: Cognitive Level: Analysis REF: p. 34

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

12. The nurse is caring for a critically ill patient on mechanical ventilation. The physician identifies the need for a bronchoscopy, which requires informed consent. If the physician were to obtain consent from the patient, the patient must be able to:

a.

be weaned from mechanical ventilation.

b.

have knowledge and competence to make the decision.

c.

nod his head that it is okay to proceed.

d.

read and write in English.

ANS: B

Informed consent requires that a person know what is to be done and have the competence to make an informed decision. Most critically ill patients do not have this capacity; however, an assessment should be made to determine the patients capacity. Some patients on mechanical ventilation are able to give written consent. Reading and writing in English are not requirements for informed consent.

DIF: Cognitive Level: Analysis REF: p. 30

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

13. The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a do not resuscitate order written on the chart. What is the appropriate nursing action?

a.

Contact the attending physician immediately to determine if CPR should be initiated.

b.

Contact the family immediately to determine if they want CPR to be started.

c.

Give emergency medications but withhold intubation.

d.

Initiate CPR and call a code.

ANS: D

Because no orders have been written, it is imperative that a code be called. In this example, decisions regarding resuscitation status should be determined as soon as possible before a code event. The physician and family should be contacted immediately to determine treatment options, but CPR is not withheld. It is not appropriate to conduct a partial code by giving medications only.

DIF: Cognitive Level: Analysis REF: p. 33

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

14. When addressing an ethical dilemma, contextual, physiological, and personal factors of the situation must be considered. Which of the following is an example of a personal factor?

a.

The hospital has a policy that everyone must have an advanced directive on the chart.

b.

The patient has lost 20 pounds in the past month and is fatigued all of time.

c.

The patient has told you what quality of life means and his or her wishes.

d.

The physician considers care to be futile in a given situation.

ANS: C

Personal factors include competence, stated wishes, goals and hopes, definition of quality of life, and family relationships. Hospital policy is a contextual factor. Weight loss and fatigue are physiological factors. The physicians belief is a contextual factor.

DIF: Cognitive Level: Analysis REF: Figure 3-1

OBJ: Apply the components of a systematic, ethical decision-making model.

15. A specific request made by a competent person that directs medical care related to life-prolonging procedures if the patient loses capacity to make decisions is called a:

a.

do not resuscitate order.

b.

healthcare proxy.

c.

informed consent.

d.

living will.

ANS: D

A living will is a formal advance directive that directs medical care related to life-prolonging procedures when a person does not have the capacity to make decisions regarding health care and treatment. A do not resuscitate order is a legal medical order prohibiting resuscitation measures in the event of clinical death. A healthcare proxy is an individual designated by the person to make decisions if incapacitated. Informed consent involves decisions regarding treatments and procedures following explanation of risks and benefits.

16. The American Nurses Credential Center Magnet Recognition Program supports many actions to ensure that nurses are engaged and empowered to participate in ethical decision making. Which of the following would assist nurses in being involved in research studies?

17. The critical care nurse wants a better understanding of when to initiate an ethics consult. After attending an educational program, she understands that the following situation would require an ethics consultation:

a.

Conflict has occurred between the physician and family regarding treatment decisions. A family conference is held, and the family and physician agree to a treatment plan that includes aggressive treatment for 24 hours followed by re-evaluation.

b.

Family members disagree as to a patients course of treatment. The patient has designated a healthcare proxy and has a written advance directive.

c.

Patient postoperative coronary artery bypass surgery who sustained a cardiopulmonary arrest in the operating room. He was successfully resuscitated, but now is not responding to treatment. He has a written advance directive and his wife is present.

d.

Patient with multiple trauma and is not responding to treatment. No family members are known, and care is considered futile.

ANS: D

In the case of a seriously ill patient who is incapacitated and does not have a surrogate, an ethics consultation is warranted. The conflict has been resolved in the case of the family and physician agreeing on a course of treatment for 24 hours followed by re-evaluation. Although family members disagree, if a patient has a written advance directive and a designated healthcare proxy, an ethics consultation is not warranted; the patients wishes are clearly known. The cardiac surgery patient has a written directive to guide his treatment.

18. The nurse is aware that a shortage of organs exists. She knows that which of the following statements is true?

a.

Anyone who is comfortable approaching the family should discuss the option of organ donation.

b.

Brain death determination is required before organs can be retrieved for transplant.

c.

Donation of selected organs after cardiac death is ethically acceptable.

d.

Family members should consider withdrawing life support so that the patient can become an organ donor.

ANS: C

Donation of selected organs after cardiac death is ethically and legally appropriate. Specific policies and procedures for donation after cardiac death facilitate this procedure. Only designated requestors who are knowledgeable and trained in organ donation should approach the family to discuss donation. Organs can be retrieved not only after brain death but also after cardiac death. The decision to withdraw life support should be made separately from the decision to donate organs.

2. The nurse is caring for a patient whose condition has deteriorated and who is not responding to standard treatment. The physician calls for an ethical consultation with the family to discuss potential withdrawal versus aggressive treatment. The nurse understands that applying a model for ethical decision making involves which of the following? (Select all that apply.)

a.

Burden versus benefit

b.

Familys wishes

c.

Patients wishes

d.

Potential outcomes of treatment options

ANS: A, C, D

According to the ethical decision-making process, decisions should be made in light of the patients wishes (autonomy), burden versus benefit (beneficence), other relevant principles, and potential outcomes of various options. The patients wishes may differ from those of the family.

DIF: Cognitive Level: Analysis REF: p. 27-28 | Fig 3-1

OBJ: Apply the components of a systematic, ethical decision-making model.

3. The nurse understands that many strategies are available to address ethical issues that may occur; these strategies include which of the following? (Select all that apply.)

a.

Change-of-shift report updates

b.

Ethics consultation services

c.

Formal multiprofessional ethics committees

d.

Pastoral care services

ANS: B, C

Formal mechanisms such as multiprofessional ethics committees or referral services are strategies to address ethical issues. Nurse-to-nurse communication can help share information from shift to shift, but it is not the best way to address ethical issues. Pastoral care representatives may serve on an ethics committee; however, their primary role is to support the spiritual needs of the patient and family.

4. The nurse is caring for a patient with severe neurological impairment following a massive stroke. The physician has ordered tests to determine brain death. The nurse understands that criteria for brain death include: (Select all that apply.)

a.

absence of cerebral blood flow.

b.

absence of brainstem reflexes on neurological examination.

c.

Cheyne-Stokes respirations.

d.

flat electroencephalogram.

ANS: A, B, D

Criteria for brain death include absence of cerebral blood flow, absence of brainstem reflexes, and flat electroencephalograph. The presence of Cheyne-Stokes respirations would indicate some brain function.

DIF: Cognitive Level: Analysis REF: Table 3-2

OBJ: Discuss ethical and legal issues that arise in the critical care setting.

5. The nurse is caring for 80-year-old patient who has been treated for gastrointestinal bleeding. The family has agreed to withhold or withdraw additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued. The nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.)

a.

Do not resuscitate.

b.

Change antibiotic to a less expensive medication.

c.

Discontinue tube feeding.

d.

Stop any further blood transfusions.

ANS: A, D

All orders except antibiotic adjustment may be considered withdrawal or withholding of life support and should be written only after informed consent from the healthcare surrogate or family has been obtained. Because the patient has expressed a request to not have food or fluids withdrawn, it would not be appropriate for the physician to write an order to discontinue the tube feeding.

DIF: Cognitive Level: Analysis REF: p. 33

OBJ: Discuss ethical and legal issues that arise in the critical care setting.